The Atlanta region’s healthcare system, and Georgia as a whole, has long struggled in the face of systemic silos. Disjointed hospital networks, inaccessible social services, and administrative divides have left patients, especially those in under-resourced communities, navigating a fragmented continuum of care.
To address these barriers, the Atlanta Regional Collaborative for Health Improvement (ARCHI) has been expanding a regional collective action model. The strategy heavily relies on Community Health Workers (CHWs)–trusted neighborhood personnel who coordinate care between patients, clinical teams, and essential social support.
On Wednesday, Oct. 21, ARCHI members and Mayor Andre Dickens gathered to share updates on their progress and outline the remaining challenges in building a connected regional system.
Dickens opened the morning event by sharing how his signature Neighborhood Reinvestment Initiative aligns with ARCHI’s mission to shift the administrative burden away from vulnerable patients and onto system processes.
“We must address the conditions that contribute to poor health: housing stability, food insecurity, limited access to transportation and economic opportunity,” Dickens said, emphasizing social determinants of health alongside clinical care. “Our healthcare and human services systems have operated as silos for far too long.”
To bridge these sectors, Dickens’ administration set aside housing units for Project HEAL, which helps homeless residents secure housing upon hospital discharge.
Early success of community health workers
ARCHI members echoed Dickens’ concerns, noting that these operational silos hurt both providers and patients alike. For clinicians, disjointed networks make it nearly impossible to share vital patient data; for patients, it creates a bureaucratic maze to navigate alone.
To untangle that bureaucratic maze, investments in the CHW initiative are already yielding tangible returns. Executives from Grady and Emory shared success stories ranging from an isolated elderly patient enabled to live independently at home, to high-utilizer patients safely navigating transitions between major hospital systems like Grady and local community clinics.
Kaiser Permanente Georgia Chief Operating Officer Hiral Patel noted that Kaiser’s CHW initiative has enrolled 2,000 of its members, with a 79 percent acceptance rate. “If you lend out a hand, a voice, a place to land concern, people take it and they embrace it,” said Patel.
To sustain these community-level wins, ARCHI leadership is pushing to formalize and standardize the frontline workforce. Jeff Smythe, Executive Director of ARCHI, emphasized that securing state-level certification for CHWs is essential for universalizing professional expertise and opening sustainable funding pipelines–specifically laying the groundwork for future Medicaid funding.
“These connectors with their own lived experience are so valuable to the whole system,” said Smythe. “If there’s a way to make that more standardized across Georgia, particularly in rural Georgia, it’s going to be really effective.”
Policy barriers and the push for private funding
Universal workforce standards require state policy changes, while broader efforts remain constrained by Georgia’s decision not to fully expand Medicaid. Some private sector leaders argue that regional progress does not need to wait on legislative shifts in Atlanta or Washington.
Speaking from the insurer perspective, Lisa Porter, Director of Health Equity Strategy at Humana, stressed that communities can build sustainable funding by rethinking how private insurers and healthcare providers collaborate.
“There is still money to do this. We don’t have to rely on Medicaid expansion,” said Porter, calling on regional health insurance companies to co-invest in community health infrastructure. “We can think more creatively and collaboratively about the contracts that we have in place, about the partners that we have in place, and the infrastructure that exists to involve that sustainable economic layer into this work. We can build it before Medicaid expansion ever comes to the state of Georgia… And I’m going to challenge my fellow [insurance] payers in the room: We can do it, too.”
Achieving that scale, however, will require more health insurers to pull up a seat to the table.
Building a legal structure to scale
Coordinating these separate institutions presents a complex logistical challenge. Without a central legal entity to manage multi-party financial contracts and safeguard patient privacy across competing health systems, sustaining this joint infrastructure remains difficult.
ARCHI currently operates as a neutral facilitator for the region, which has been instrumental in building collaboration across competing health systems. ARCHI leadership is actively exploring whether to become a standalone 501(c)(3) nonprofit or create a separate entity to manage operations. Whatever form it takes, Smythe emphasized that changing systems requires deliberate, permanent structure.
“If you’re not intentional about changing systems, the systems will go back,” warned Smythe. “We’re going to redesign systems. We’re going to put people at the center.”
